Shane McGowan is a sad man, ferociously ugly and a terrible alcoholic. He is in the running for the worst teeth in Western Civilization. But he wrote some of the saddest and most beautiful songs I have ever heard.

I've had a couple of days off work now, and it being close to Festivus, I've spent a fair amount of time driving back and forth from the mall, parties, various errands, etc. I tend to listen to news radio (at least until the commercials start driving me crazy and I have to turn on my iPod), and I've also caught some of the nightly teevee news. The lead story, of course, has been the deal and imminent passage of the Senate health care bill.

Now, I've been like, all-health-care-reform, all the time for about eleven months now, and so deep in the weeds that, for me, the big news was that Wyden got a modified version of his "Free Choice" amendment into the bill. Woo Hoo, amIright? But being so deep into things, I rarely gave much thought into the "How's this going to play in Peoria?" argument. Further, since the Senate deal involved a gutting of the most progressive provisions, which has sparked the traditional round of fratricide in Left Blogistan, it certainly has not felt exactly like something to celebrate so much as something to swallow.

So I was a little surprised by the tone of the Emm-Ess-Emm's coverage. It was laudatory, even triumphant. It intoned gravely about the "historic" passage of reform. There were clips of Obama praising the bill. There were the obligatory counter-clips of GOP back-benchers grousing about the bill being Bad For America, but overall, the subtext was this:

Obama/Democrats Win Big.

Seriously? No mention of the horrible price Lieberdouche exacted for his support? No mention of the humiliation of the Senate leadership by the Conservadems? No "Obama forced to accept crappy-ass compromise" storyline? Nope. Wow. Sure, there was the obligatory mention of the "controversial" public option and its death, but in the context of "Obama Wins" this was relegated to no more than a brief aside. Bear in mind that I'm talking network news, NPR and local news outlets mostly, not the WaPo or other "insider" publications.

It is, of course, not yet a sure thing that the whole bill will ultimately pass. Byrd is only barely still legally alive, and the thing could fall apart in conference if the House refuses to sufficiently abase itself before the awesomeness and glory of the Senate. If it does, however, this really is a win. It's a win as it is judged by the most important arbiters: the voters who are outside of the beltway and not intimately interested in the details of policy. Yes, I know that reform polls poorly right now; that's to be expected given the controversy and continuous attacks on the proposals. Once there is a final bill enacted into law, the coverage shifts from "beleaguered reform" to "reform triumphs" and the proponents get to take a victory lap in the media touting the great things the reform does contain. (And that's even before the goodies start to get handed out.) I suspect that public opinion will swing back in favor of the reforms, and the majority of people who are not directly impacted will file it away under "Well, that's settled, then, isn't it?" and go back to watching So You Think You Can Dance.

This is not to dismiss the anger of the teabaggers -- I do not doubt that it is real. I also do not doubt that the Democrats will lose seats in 2010. It's a natural year of retrenchment. However, it would have been pure suicide for the Democrats to have embarked on reform and failed to deliver. That would have set the stage for 1994 redux. If reform does pass, economic fundamentals being what they are, the Dems will lose seats in both chambers, though I doubt they'll lose control of either, but they'll lose far fewer than they would have if reform had failed.

If health care reform, the linchpin of Obama's and the congressional Democrats' election campaigns, were to fail, it would send the following message: Democrats are incompetent and cannot be trusted to govern. (Which may not be too far from the truth, politically. Insert Will Rogers joke here.) Voters can accept partisanship, but they are not tolerant of incompetence. (See 2006 and Katrina.)

Obama understands this. He understands that the Public Option or any of the other liberal shibboleths could and must be discarded if that if the price to get the vehicle across the finish line. Which is why he never threw his weight behind it or drew any lines in the sand. He is prepared to sign anything Congress gives him, and it's a happy coincidence that the "final" reform bill is looking to be flawed but highly worthwhile. It may not be the eleven-dimensional chess his supporters credited him with, but it is the hallmark of a relatively savvy political operator. If and when he gets to have the big signing ceremony, he will reap the rewards of his pragmatism.

21 December 2009

By a vote of 60-40, the Senate agreed to end debate on a major package of health care amendments--and by doing so, signaled that the Democratic caucus is unified, and ready to pass a far-reaching reform bill straight down party lines.

Finally, health care reform is in the home stretch.

I've not written much about this lately because, frankly, I haven't had too many original insights. Also, it's been such a rapidly-moving target that it's difficult to take a position on a new proposal before it's dead and the senate has moves on to something else entirely. I still haven't much more to say than has been said many times elsewhere, but just for the record:

This is a great bill, and a historic accomplishment for the Democrats.

Am I disappointed? Yes. It's a flawed bill, and could have been much better. The process could have been better handled. Why Baucus was allowed to string out the Gang of Six negotiations so long is a mystery. Why the White House didn't take a more active role will be long debated. The politics were and are atrocious. It's frustrating to see a republican caucus more dedicated to obstruction than to the national welfare. It's frustrating to see douchebags like Lieberman and Nelson hold the whole thing hostage at the last minute. On the other hand, it was pointed out that the whole thing was, in a way, made possible by the conservative Club for Growth. When they targeted Arlen Specter for a primary, he became a Dem, without whom they would not have had 60 votes. Isn't life funny?

I do wish that we had obtained a meaningful government-run insurance option, but I console that loss with the fact that we did get:

$880 Billion in subsidies for the vulnerable poor to obtain health insurance

About 95% of all Americans covered; not universal, but close

Great regulations on insurance companies' abuses: community rating, guaranteed issue, no recissions

Competitive marketplaces where insurers must compete against one another: the Exchanges

Fiscal responsibility: a deficit-reducing bill

A strengthened Medicare Commission

Payment reforms

If you'd made me this offer in 2006 I would have jumped at it. It's a great start. It's more than Clinton could do, and it's success where Carter, Kennedy, and Truman failed. I can live with it, and support it enthusiastically. And I'll also support improving it and modifying it as soon as President Obama's ink is dry on the final legislation.

But I don't want to count my chickens just yet. There's a conference committee to get through, and neither the House nor the Senate Dems can spare any more defections if the final bill is to pass. Health care reform is still terribly tenuous, but it is at this point looking likely to pass.

18 December 2009

I got to work last night at eleven pm, to find two doctors and one PA sitting there playing with their fingers and staring at the ceiling. There were maybe five patients in the entire department. So I sent the other guys home. They were all scheduled to leave in the next couple of hours anyways.

Predictably, in the hour after they all left, nine patients registered, and I wound up seeing a grand total of 24 patients in the last six hours of my shift, including a head bleed, an emergent dialysis with potassium of nine, and a DKA. Never sat down to eat much less anything else.

Gaah. Of course it's my own fault for daring to send them home, and for bringing work in to do on the shift. Everybody knows that ER volume is directly proportionate to the amount of reading material you bring in!

The only silver lining is that the last patients were reasonably simple and I walked out of there thirty minutes after the end of my shift. I was so stupid from lack of sleep I could barely figure out how to get the keys into the ignition of my car.

17 December 2009

As was widely reported, the Boeing 787 finally took flight the other day, only two years behind schedule. I was lucky enough to watch live on Boeing's web broadcast as the Dreamliner took off from 34L at KPAE. I used to live in the traffic pattern for that runway, and I still kinda miss all the planes flying over my house.

One thing really caught my eye watching the plane in silhouette, flying off into the misty sky:

HOLY CRAP ARE THOSE WINGS FLEXING.

Seriously, check this out:

and this

Wowie. The wingtips appear to be elevated above the top of the fuselage. As amazing as they are, these screen grabs understate the degree of flex that was apparent in the initial video.

According to this, the wingtips can flex up as much as 26 feet! (though that's at 150% of max load.)

The visual effect was elegant, graceful and beautiful, to be honest. It looked very much like a bird soaring. But I wonder how comfortable passengers will be looking out the windows and seeing the unmistakable upwards curve in the wing? (Note: conventional airliners' wings also flex, but the effect is not as noticeable.) I guess that's what happens when you build a plane out of plastic. Also, the linked blog speculates that if they do a wing-break test, the wings might be so strong/flexible that the wingtips could actually meet over the top of the fuselage. How cool would that be?

I've not been blogging much lately because of work craziness and traveling. One of my recent travels, however, was not for work but for pleasure. I've been studying karate (a traditional Okinawan version called Shorin-Ryu) for over fifteen years. There's a national federation to which I belong and there are seminars three or four times a year taught by some of our more senior instructors. This was one such seminar, and it focused on joint lock and grappling techniques, some of which our style shares in common with other martial arts such as Akido and Judo.

At one point I was working with a fifth-degree black belt instructor, "Bill." Super nice guy, and absolutely amazing in his speed and techniques. He was also very kind in teaching me a number of useful tricks and nuances of the techniques we were working on. There was a sequence which culminated in a choke-hold, and he was unhappy with the manner in which I was choking him. We stood facing one another, and he demonstrated on me, reaching in with thumb and forefinger held claw-like and squeezing behind my trachea towards the base of my tongue.

It really hurt.

As he demonstrated, several other students gathered around to watch. While Bill held on to my throat, I reached out and mirrored the choke hold on his. "Is this right?" I asked.

"Not quite," says he, "You need to reach up more, like this." He squeezed a bit harder and I nearly went to my knees. I adjusted my grip and squeezed some more.

"Like this?""Yeah, that's about right," he gasped in a somewhat strangled voice, increasing the pressure on my throat once more.

So I responded by squeezing a bit more, and he did the same. I could feel his internal carotid pulsations quite distinctly underneath my fingertips. We stood there, pained smiles on our faces, and looked at one another for a bit. An unspoken question hung in the air: "How long are we going to let this go on?" It was only a matter of time (seconds, in all likelihood) before one of us lost consciousness. It seemed like it lasted forever, but after a few moments, by mutual agreement we pushed one another off to general laughter.

In karate seminars, it's always funny to watch people hurting each other. I don't know why.

That evening, back at the hotel, a large number of us went down to the hot tub to soak our bruises. The warm water soothed the pain, as did the beer we imbibed. I noticed Bill was not getting in the tub, but sitting by the side. I asked if he was not going to join us, and he demurred: "I can't use hot tubs," flashing a medic alert bracelet, "I have a heart condition and I am on coumadin."

It took a moment for this to sink in. Coumadin is a powerful blood thinner, and something of a mixed blessing. If you are prone to life-threatening clots, it can be life-saving. But it has so many complications, usually in the bleeding line: bleeding ulcers, severe bruising, and significant sensitivity to even minor trauma. My mind flashed back to earlier when my fingers had been wrapped around his windpipe.

"Holy crap!" I blurted out, "You're on coumadin and you let me squeeze your trachea? Are you out of your mind? What's your INR?"

"2.8," he responded, confirming that his blood was indeed adequately thinned. He laughed. "It's no big deal. I don't even bruise." It was true. He showed me his forearms, free of the bruises that were already flowering on my own. "My doctor says it's OK for me to do karate. He brags about me all the time."

"I'm going to brag about you, too," I responded. "But I still think getting into the hot tub probably wouldn't have been the most dangerous thing you've done today." He laughed and handed me another beer.

I checked his throat the next day -- not a mark to be seen. I tried not to be too mindful of his anticoagulation when we sparred, but it made no difference in any event -- he kicked my ass so thoroughly that I never had a chance to injure him!

It still makes me shake my head. Is there a worse possible hobby for someone on coumadin than martial arts? The mind reels.

Assuming for a moment that your ER group’s ability to pay you fair compensation for your services is to some extent dependent on the group being able to get the best possible terms in the managed care contracts the group negotiates with commercial, Medicare and Medicaid managed care, and self-insured indemnity plans: here are some considerations that might be important to you.

10 December 2009

Security is an issue in the ER, and we try to be careful about it. Patients and their families have been known to stalk physicians, nurses, and other staff. Most nurses don't have their full names on their badges for that reason, and we don't give out the doctors' schedules or anything like that. I didn't think anything of it when I came in for a shift and the unit clerk told me that some patient's family member had been calling for me. They didn't say what it was for, and the clerk didn't get their name, and I shrugged it off. The next day, they had called again. Once more, there was no name or message, but it made me distinctly uneasy that there was someone out there who really wanted to find me. Who was this? Some drug seeker, angry that I had not been free enough with the oxycodone? Some process server with a notice of a malpractice allegation? One of my many female admirers? The mind reels.

The next day, once again, there was a message waiting for me. This time it was the charge nurse who had taken the call, and she had gotten some more information: it was Mrs Jones, who wanted to meet me and thank me for "saving her husband's life."

Comprehension dawned.

I had almost forgotten about the megacode of last week. I looked Mr. Jones up in the computer and saw that he was doing very well. So when I got a moment I went back up to the ICU to check in on him.

He was asleep, but his daughter was at the bedside. She was a beautiful young woman, in her late teens or maybe twenty years old. I introduced myself and we chatted; she wept and thanked me profusely for our efforts. She told me how great her dad was, and how much it meant to have him still around. Eventually the noise woke him up and he asked me who I was. I introduced myself as one of the doctors who had worked on him when he had his cardiac arrest. Too late, I saw her frantically waving her hands behind him, clearly mouthing the words, "We haven't told him!"

"I had a cardiac arrest?"

Awkward. "Um, yeah. A little one. Nothing much really."

"So what did you all have to do to me?"

"Well, we just ... ah ... pushed on your chest a bit and gave you some medicines."

"Oh." He mused a bit. "So that's why my ribs hurt."

He let it drop, and we had a nice conversation. He thought it was 2006, but otherwise was pretty oriented. A fellow Bears fan, we talked football. He asked how Jay Cutler was working out. Awkward. "He's had some good games, but a few rough ones. I think he could use some more support from the offensive line." I didn't have the heart to tell him about Favre.

On my way out, he stopped me. "So doc, was I dead? Was it pretty bad? How close was I?"

How do you answer that? It's hard to be honest when you don't want to agitate someone who is still pretty ill. I went for the euphemism: "Well, your heart wasn't beating effectively, so you were unconscious. From your perspective, it was more like a prolonged fainting spell. But you're still here, so clearly you weren't dead." One of my old professors had liked to say that the difference between fainting and dying is that you wake up. That seemed to satisfy him, and we parted.

I had given my card to his daughter, and Mrs Jones and I traded emails and voice messages for several days till we finally hooked up. She and her youngest son came by the ER and she enveloped me in a crushing hug. I'm not usually the hugging type, but in cases like this I can make an exception. She told me in very affecting terms how grateful they were to all of us. Her nine-year-old told me, in the non sequitur manner of the young, that he had just gotten his black belt in Tae Kwon Do. She told me about her husband's work, the church he runs, how he was the glue holding their family together. I told her that I was just one part of a large team that had done the work. She left, still wiping tears, promising to bring cookies to the ER for us to enjoy.

There are so many codes I've run. So many times I've told families that their loved one is dead and gone forever. So many times I've left the room to the sound of strangled sobs and tears. Bad outcomes are the rule, perhaps not surprising in a situation when the patients come in already dead or actively in the process of dying. So many times I've called the ICU doc for the admission after resuscitation, knowing that the pathology -- the head bleed, the anoxia, the sepsis, etc -- is overwhelming and undoubtedly lethal. Like many health care providers, I too become habituated to death, jaded by the inevitability of mortality, enervated by the futility of the rigmarole.

These few cases, the happy endings: they are so rare, and when they do happen so often they are so utterly unexpected, like a bolt from the blue, that when someone defies the odds and defies all logic in surviving and not only surviving but doing so unscathed it doubles and triples the delight we take in their good fortune. It reminds us not to be cynical, that though you do CPR on a hundred people, not all of them will die, so you should focus your effort and energy on the one whose chest you are compressing right now, because this might be the one who makes it all worthwhile. That's the payoff -- a dozen cases and more of suffering and tragedy for the one whose wife hugs you and promises you cookies. That makes it all worthwhile.

08 December 2009

It's the question an ER doctor hates, guaranteed to make each and every one of us cringe somewhere deep down inside:

"Hey, remember that guy from the other day?"

Oh God, you think to yourself, which guy is she talking about? That one with the funny dizziness? Dammit, I knew that was a stroke and the fucking neurologist said it was OK to send him home. I should never have listened to him! But you remain composed and smile and say "Which guy?"

Then you sit back and prepare yourself for the worst. And it is usually bad. C'mon, we work in the ER. Bad things happen here, and bad things happen to people after they are seen here. So it was with surprise that I saw the charge nurse smile and say, "You know, that guy you coded upstairs the other day? I just talked to Jenny in the ICU and they say he's doing great. He's going to be extubated this afternoon!"

"Seriously?" I was really and truly shocked. That guy was dead. Totally dead. Blue and with no brain activity. We coded him forever, and when the code finished with him still alive, we all knew deep down inside that at best we had saved organs for harvesting, that the probability of a decent neurologic outcome was nil.

Turns out that the ICU doc had gotten started on the hypothermia protocol right away and this may have done the trick. I ventured up to the CCU later that day and thumbed through the chart. No clear evidence as to the cause of the arrest, though smart money is still on PE. He wasn't extubated yet, but all signs were highly positive and he was indeed looking like one of those rare happy outcomes from a cardiac arrest. The ICU doc teased me, "What are you doing way up here? I thought you lived in the basement! You're going to get altitude sickness." I stole a line from Greg Henry, saying "I'm just here to make sure you're taking good care of my patient." I stopped in at the bedside but he was still pretty sedated and there was nobody there at the moment, so I took off back to the ER.

Five years ago, heck, two years ago, we weren't doing the therapeutic hypothermia drill and this would not have been such a happy thing. Amazing what developments creep up on you in the course of practice, and amazing how they translate into human outcomes. I was kind of bummed that I had missed the family, but such is life. Mostly I was bemused and gratified that our rather extraordinary efforts had borne unexpected fruit.

They're not allowed to actually write "Hey Dummy, look here" on the x-ray report, but this is what the radiologists do when they want to make sure the idiots in the ER won't miss the key finding on a film (in this case, a bit of glass from an automobile window):

The wonders of digital radiography allow this to appear on my computer screen. In the old days they did it with a grease pencil and a post-it note.

07 December 2009

Several outlets are reporting, and I can confirm, that Senate Democrats are considering a Medicare expansion as one item on a menu of concessions conservative Democrats would agree to in exchange for weakening or eliminating the public option in the health care bill.

Currently, Medicare exists as a single-payer system for seniors 65 and older. According to Hill sources, the idea would be to allow people under the age of 65 to buy in to Medicare. The option would be limited to people older than a certain age, though that age--and indeed the entire proposal--has yet to be agreed upon.

Not as good as a strong public option, but a strong public option ain't in the cards, and a neutered one is barely worth the fight. This is better than nothing, and since "nothing" is looking more and more likely what the progressives might get, I'd take it. From a simple political perspective, liberals have been getting rolled again and again by the centrists and conservaDems, so this meaningful expansion of Medicare represents a genuine "win" for liberals, and those have been in short supply lately.

I have to see the details and think through the policy implications (adverse selection, anyone?) before a final judgment. Still, this looks god ont he face of it. One more thing: Open the exhanges!

Color me unsurprised that Barack Obama didn't mention the public option in his remarks to the Senate last weekend. One of the dynamics that hasn't really penetrated in this debate is that the Obama administration is mainly interested in the cost controls. The president will throw the public option overboard if Susan Collins asks him nicely. Conversely, Peter Orszag will lay down in traffic to save the Medicare Commission. Generally, Democrats want to reform the health-care system because they want to cut the number of uninsured. The Obama administration's commitment to health-care reform stems from their belief that it's the first step towards cutting long-term deficits.

In a lot of ways, Obama is proving to be a much more conservative President than one might have expected. Despite how the teabaggers might want to portray him as a raving liberal, he's decidedly not. Lord knows he's disappointing his liberal base, myself included, on many issues, with his cautious and often centrist approach. I'm inclined to give him the benefit of the doubt and trust him, since if nothing else he seems to be taking a very responsible line. On this point, he is probably right -- that long-term cost control needs to take precedence over the liberals' fantasy dream plan for health care reform.

At our hospital, the overhead paging system is fairly infrequently used. At 8:30 PM they announce that visiting hours are over and will all guests please get the hell out go home, and, being a religious institution, they pray at us twice daily. A little musical scale is played when a baby is born (an arpeggio going up the scale if a girl, down scale if a boy; I've long wondered if there's a subtle message to be had there). After working there a decade, I've learned to ignore these routine announcements completely. Then there are the "codes" that are called overhead. These are preceded by a chimed single note (a middle D, I think) and followed by the specific code. There's the "Code Blue" which is, of course a cardiac arrest, and there are the trauma codes: these are for me. Code Red is a fire and Code Gray is for the security team: I ignore them. Patients must think I have a strange tic because if I hear the chime while we're talking, I stop in mid-sentence and cock my head to listen whether it's a code I have to respond to. If it's not one for me I pick up where I left off, but if I have to run from the room, patients usually understand.

So it was the other day. I was giving a guy with strep throat his discharge instructions when the Code Blue was called. I bolted upstairs and arrived at the room as several nurses were heaving a large man back into bed. There's that "doorway moment" when you hit a code, in which you make an instantaneous, almost subliminal assessment of how bad the situation is. "Very bad," was my thought as I moved to the head of the bed. The patient was dusky blue and covered in sweat. He was a middle-aged man, mildly obese, with a full head of dark brown hair. He had no respiratory efforts and was completely flaccid. Within moments I had him intubated, they were back doing CPR, and a monitor was being hooked up.

There was no pulse and the monitor showed a flat line, meaning no cardiac electrical activity at all. It was a weird code: an otherwise healthy guy admitted for a simple pneumonia. Not the sort of patient you expect to drop dead on you with no warning. He had just gotten up to go to the bathroom, his nurse explained. The down time before I tubed him was probably five, maybe ten minutes, we guessed.

Generally speaking, when someone dies suddenly, you've got a few minutes to get them back. Every passing minute makes the likelihood of a successful resuscitation diminish drastically. And the minutes dragged on and on in this code with no response whatsoever. There was a progressively increasing sense of fatalism among the dozen or so health care providers gathered around the bed, working to save this man's life. This guy was dead. He was not coming back. Uneasy glances were exchanged. The urgency and crispness drained out of the room. The initial energetic, high-quality CPR was replaced by slower, weaker chest compressions. People shook their heads and checked their watches. The unspoken question, "How long are we going to flog this?" hovered in the air.

That's my decision, and sometimes it's a hard one. The really and truly dead are pretty easy to call, but this guy was "still warm," as they say, and I wasn't quite ready to give up. Besides, he was showing me a few things on the monitor which at least kept things interesting. We played with it like a mega-code, going through the different arms of the algorithm: asystole, V-Fib, V-tach, bradycardia, PEA and more. I gave some helpful feedback to the folks doing CPR, even venturing a few bars of "Stayin' alive," to rueful chuckles. Some gallows humor was exchanged. But there was a very deep, very firm conviction among the entire team that by this time we were going through the motions, and the outcome was now set in stone. The chaplain was trying to get the patient's wife on her cell phone, and I called the primary care doc. The patient's complexion never altered a whit from that deep violaceous hue, and there were no signs of life beyond the squiggles on the monitor, never associated with a pulse.

On a lark, we decided to try t-PA, a clotbuster drug, in case there was a blood clot in the lungs causing the arrest. I was chagrined to learn, after ordering it, that it was going to take 5 to 10 minutes to prepare. "We have to keep doing this for another ten minutes?" I thought to myself, but having ordered it I felt like it would have been obscene to reverse myself because it was inconvenient. So we rode it out and kept going while the drug was prepared and run up from pharmacy, keeping ourselves entertained during the interim by fiddling with pointless vasopressor drips.

Good thing we did: as the t-PA arrived at the bedside, before it was hooked up, suddenly the chaotic cardiac tracing became more organized and normal-looking. The respiratory therapist murmured in amazement, "Hey, there's a pulse!"

"It won't last," I thought to myself, "It never does." But to my surprise it did. This development, if anything, further depressed the mood in the room. We had been coding him for fifty minutes. That's an eternity, and without oxygen for that long his brain was so much scrambled eggs. Someone made a coarse remark about a tracheostomy and a nursing home, which reflected the sinking feeling that it would have been better at this point for him to have died.

When the ICU doc started getting prepped for an arterial line, I knew my part in this drama was over. The ER nurse and I made our exit, stripping off our gloves. "It's Miller Time," she quipped, and we both convulsed with silent laughter as we stood at the elevator. Back downstairs, the guy with strep was really annoyed at having had to wait for a solid hour for his discharge.

I got a surprising number of comments on my post from Friday about Aetna. To recap: Aetna's profit margin this year was less than in previous years. It was, however, still profitable and in fact beat analysts' expectations. Aetna made the decision to raise premiums to improve their profit margin; this, according to Aetna, will result in 650,000 individual group and individual members losing their insurance from Aetna.

First of all, I need to point out to all of you commenting on this post that you're not helping me out here. I'm trying, I really am trying to get away from the policy stuff and get away from the political stuff and get back to the clinical and humanistic side of medical blogging. And I put up a throwaway repost of something from the Huffington Post and you go and spark an interesting discussion in the comments. And I'm drawn in like the moth to the flame. You're killing me.

On the substance of the matter: In a fit of pique I called Aetna "fuckers," which creates a reasonable impression that I think Aetna was somehow behaving reproachably. Well, sort of, sort of not. My feeling is that Aetna is behaving perfectly appropriately within the system as it exists, but the for-profit insurance model itself should be abolished. In the current world, Aetna has a fiduciary responsibility to its shareholders to maximize their profits. It's not just a good idea; it's the law. Moreover, Aetna is traded on the NYSE, and like any other publicly traded company, if investors are concerned that profits are in jeopardy, the stock will plummet and stockholders will suffer. So the executive team at Aetna has a real and genuine mission to maximize profit, and to make a public show of how hard they are trying to maximize profits. It's their reason for being. They took a rational look at the market, made the profit/volume calculation, and decided they were better off selling fewer donuts at a higher profit per donut.*

Which is a fine thing to do if you're selling donuts, but Aetna is insuring lives. It's a little galling to see the profit/life calculation being made so brazenly. But in fairness, it should be pointed out that some or most of the 650,000 people who can no longer afford or no longer choose to pay Aetna's higher prices will not become uninsured or go on welfare. Some may wind up uninsured (especially in the horrific small business/individual market), but the larger number, especially in the large group market, will simply elect a different option, be it UnitedHealth or one of the Blues or whomever.

So why is this a problem, if it's mostly one insurer shuffling off customers onto its lower-margin competitors? Simply: Aetna is doing this in part as a form of cherry-picking, what insurance types call "adverse selection." They want to retain the lowest-cost, healthiest customers, and get rid of those who have medical conditions that cost money. One of the most efficient ways to do this is to raise overall costs. The individuals (and the smaller groups) who have expensive conditions are already paying more due to their higher loss ratios, so they are the most sensitive to cost -- and the first customers to leave in search of cheaper insurance. Devilish, isn't it? While this is a win for Aetna (and yes, *every* insurance company does this), it distorts the market when companies are successful at it. The result is segregated pools of sicker people with higher costs. This drives up the overall cost of insurance for those who need it the most and defeats one of the key purposes of insurance in the first place: risk-sharing.

The trickle-down consequence is that the number of the uninsured inevitably increases as all the companies engage in this practice of profit-maximization. Some of the 650,000 soon-to-be-former Aetna members will wind up uninsured. But as most move down the food chain of insurance companies, the costs increase there, and profit margins shrink, and these companies also increase the price of premiums. As a result, some enrollees at these plans will be priced out of insurance. It's not a one-to-one thing, but it's a certainty that this sort of activity contributes to the growth of the number of Americans without health insurance.

Another problem with this strategy is that it does represent a significant inefficiency in the health care market. Put bluntly, insurance company profits are expensive. The annual profits for the top five publicly-traded health insurance companies total somewhere in the $25 billion range. Yes, that's a small fraction of overall spending on health care, but it's also a full quarter of the $100 billion that the "huge" health reform bill will cost annually. As someone invested in public health, it's frustrating to see that sort of money parasitically siphoned off of a system that is already crumbling under its expense. (Note that I say parasitically not as a moral condemnation but in the strict sense of not adding value for the costs incurred.)

Would life be better if all insurance companies were not for profit? Good question. It's true that some of the most vicious, dirty players in the insurance game are not-for-profit insurers. Where markets are competitive, they behave like the for-profits. (This fact is in my opinion the strongest argument for the public option.) But as was pointed out, the not-for-profits do bear a sense of responsibilty for their communities and you seldom see a non-profit exit a market unless they have been driven bankrupt. Further, the surpluses generated by not-for-profits are generally much smaller than the profits generated by their public brethren, and they are reinvested in the business or returned to subscribers.

It wouldn't be a panacea to take the profit motive out of health insurance, not by a long shot. But it would be a good start.

And just for reference, I would generally agree that the provision of health care by physicians should also be not for profit. Which is not to say that the doctors should not be compensated -- but that the corporations should not be publicly owned and that the revenue generated by doctors should go to the doctors, not to shareholders. But that's another topic altogether.

*Side note: I grew up in Chicago, and at the Museum of Science & Industry there was a primitive computer economics game where you were the owner of a donut shop and had to figure out the optimal price for your donuts. It was fun but tough for a nine-year-old Shadowfax. Anybody else ever play that game? Says something about me that that I thought an economics computer game was "fun."

06 December 2009

HL Mencken famously said that "No one ever went broke underestimating the intelligence of the American people." Which is a great reason to be leery of polls when looking at anything other than projecting likely election results. Ezra notes an illuminating recent poll:

Vanity Fair finally had the bright idea to ask, "could you confidently explain what exactly the public option is to someone who didn’t know?" The answer:

Which is pretty much why we should not be paying much attention to polls when figuring out how to actually do health care reform. Like anybody, I'm quick to trumpet a poll that favors my position, and to pooh-pooh a poll that is adverse. But in the case of health care in particular, there's not just the problem of an inattentive and uneducated public, but also the simple fact that there are even now like five or six versions of the Public Option and ObamaCare floating around out there. How can someone know what is actually the "Public Option" when the definition is yet to be determined by Congress? And what the hell is "ObamaCare" when the multiple irreconcilable versions are being drafted by a fractious and uncooperative Congress in the (frustrating) absence of strong leadership from the White House?

04 December 2009

Health insurance giant Aetna is planning to force up to 650,000 clients to drop their coverage next year as it seeks to raise additional revenue to meet profit expectations.

In a third-quarter earnings conference call in late October, officials at Aetna announced that in an effort to improve on a less-than-anticipated profit margin in 2009, they would be raising prices on their consumers in 2010. The insurance giant predicted that the company would subsequently lose between 300,000 and 350,000 members next year from its national account as well as another 300,000 from smaller group accounts.

"The pricing we put in place for 2009 turned out to not really be what we needed to achieve the results and margins that we had historically been delivering," said chairman and CEO Ron Williams. [...] Aetna's decision to downsize the number of clients in favor of higher premiums is, as one industry analyst told American Medical News, a "pretty candid" admission. It also reflects the major concerns offered by health care reform proponents and supporters of a public option for insurance coverage, who insist that the private health insurance industry is too consumed with the bottom line.

Note that it wasn't that Aetna wasn't already profitable under the lower fee structure. It just wasn't profitable enough to keep investors happy.

Ah, it's a pity Harry Reid is such a shitty Senate Majority Leader, because if he wasn't, we'd get a meaningful public health insurance plan and put these fuckers out of business. Or at least make them duke it out with a lean competitor.

LOS ANGELES—A report published Monday in The New England Journal of Medicine warns that the nation's obesity epidemic has reached a new level of crisis, with many overweight Americans' increased girth rendering them physically unable to end their own, fat lives.

"We've known for some time that obesity can cause heart disease, diabetes, strokes, and other potentially life-threatening illnesses," said report author Dr. Marjorie Reese, director of UCLA's Obesity Pathology Clinic. "But the fact that obesity impedes suicide is truly troubling. It appears that the more reason people have to die, the less capable they are of doing so. They are literally trapped in their grotesque, blubbery bodies."

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It goes on quite a while, in spectacular detail. Click the link for the full story. Hysterical, and as they usually do, the geniuses at The Onion hit pretty close to home.

Twenty-eight degrees and severe clear. The Cascade and Olympic mountains are startlingly beautiful in the clear morning sunlight. The USS Shoup is visible at anchor down the hill in the harbor. The ER is totally empty and I just bought donuts for the staff. (It's an apocryphal but long-standing tradition that the doctor has to buy donuts when the ER is totally empty.) Not a profitable shift for me but still a nice way to begin the day.

Crummy shift the other night: 23 patients in eight hours, and 21 of them were painful. For me, that is, not necessarily for the patients. Lots of worried well, influenza, some minor injuries and a few chronic pain players. Not a single sick one in the lot. One particularly irksome case was a chronic pain patient dumped on our ER from a neighboring ER, complete with discharge instructions reading "Go to (name of our hospital)." So by the end of my shift I was pretty well burnt out. But the last two patients put an interesting perspective on the night.

The first was a 99 year-old man. Yup, that's ninety-nine years old; born prior to World War One. He was having shortness of breath and it turned out he was in congestive heart failure from what turns out to have been his fourth myocardial infarction in as many months. For multiple reasons, common sense primarily among them, he was not a candidate for aggressive intervention like angioplasty. Fortunately he had a large and supportive family, who were quite reasonable in their expectations. After a difficult discussion, we admitted him on a morphine drip for comfort care, with a hospice consult.

The second was a 9-month old with a heart rate of nearly 300 beats per minute. It was pure chance that the family had noticed that his heart felt like it was racing. To tell the truth, I'm not sure I would have noticed that on my own kids. It was an irregular heart rhythm called SVT. In adults, SVT is typically a nuisance alone and rarely requires much treatment. In small children it is similarly benign with the exception that if it is prolonged (which is common, since a baby can't tell you his heart is racing) is can cause congestive heart failure. This child was lucky in that it was caught quickly and he suffered no ill effects. One quick dose of adenosine and he was all better.

So there you have it -- the bookends on my day. Two cardiac patients: one at the very end of life, one at the very beginning. I like a nice symmetry as much as the next guy, and this was a very satisfying "circle of life" conclusion to an otherwise unrewarding shift.

03 December 2009

I've a lot to say, but haven't had the time or energy lately to blog -- work, family, real life, they so get in the way of my idle amusements. I've a few things on tap, but for the moment I'll content myself with simply linking the more interesting things I've read recently. In no particular order:

George was right - he was getting old. The nurse was right - there was nothing emergent going on.

The ER doc was wrong - George didn’t have an aortic dissection. And I was wrong - there was nothing actively wrong with his heart.

I feel badly that I contributed to a waste of healthcare resources.

No, Val, the ER doc was not wrong. You are committing the logical fallacy of ex post facto reasoning. The CT scan was clearly indicated based on the presenting symptoms because the doctor did not yet know there was no dissection. Carl Sagan once wrote of the TV scientist who sadly lamented a "failed experiment" because it did not produce the expected results. That's the exact opposite of science! Any scientific investigation in which the outcome is known in advance is a waste of time. The test was successful because it provided useful information, and while the outcome was negative, the assay was by no means a waste.

Dr Rob writes that he's also struggling with real life, and we're all hoping that he gets distracted right back into blogging soon. Until then, I have dibs on the Llamas!

Anonymity is a fantasy.It’s remarkably difficult to achieve.With small thoughts you can hide – in fact, no one cares who you are.If you offer anything worth hearing people will ultimately find out who you are.

So terribly true. I was amazed, the first time I got picked up on Reddit, how quickly some clever commenters were able to figure out my identity. Since then, I've only kept up a very slight fiction of anonymity, all the more transparent when I got cited under my real name in some national publications. The only qualification I would add to this is that I keep my name and that of my hospitals off the blog, since I don't want patients to Google me after seeing me in the ER and immediately find the blog at the top of the search list. Not that it'd be hard to make the connection, but I don't want patients I have cared for to find the blog and have the fear that "he's going to write about me." And yes, I do fictionalize every patient story on this blog extensively. Bottom line: don't post anything on line that you'd be uncomfortable listing on your CV!

Speaking of patient stories, there is a promising new ER blogger in town: StorytellERDoc. I like what I've read so far very much, and will be watching eagerly to see if he can keep up the challenging pace he's set for himself.

One another note, I liked Roger Ebert's cranky and petulant rant in the Sun Times about politicians inserting non-science-based beliefs into their public policy positions. I'd complain about the tone of the piece, but Ebert's clearly on the side of the angels on this matter, so I'll let it be. Hmm. That "angels" metaphor doesn't really work in this context, does it?

OK, gotta pick up #2 son from school now. More real medicine stuff coming soon, I promise.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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